Research led by authors from the University of Pennsylvania find widening geographic and rural-urban disparities in the story of rising white mortality rates.

Nearly 4 years ago, Princeton economists Anne Case, PhD, and Angus Deaton, PhD, published a study on rising morbidity and mortality among whites that sent shudders through everyone from demographers to politicians. More drug overdoses, alcoholism, liver disease, and suicides—so-called “deaths of depair”—meant the steady rise in life expectancy seen for decades was no longer inevitable.

Now, a new study led by researchers at the University of Pennsylvania digs more deeply into data on white mortality, including years after full implementation of the Affordable Care Act (ACA) that were not captured by Case and Deaton. Publishing in Population and Development Review, demographers Irma Elo, PhD, and Samuel Preston, PhD, and colleagues suggest that the country’s geographic divisions have become sharper and more complex. Rising white mortality has connections to education level and access to healthcare, but so far, it’s not possible to point to a single direct cause, which will make solutions equally complicated.

The authors find that for most of the 1990s, life expectancy in the United States improved. But over the past 3 decades and especially after 2010, that trend has slowed among non-Hispanic whites and women, and even reversed in some places. The opioid crisis explains part of it, but not all of it, and the bad news comes amid victories in longstanding challenges: death rates from cardiovascular causes, most cancers, and HIV are all declining.

The authors examined data from 1990 through 2016 from the National Center for Health Statistics under a data user agreement; they tabulate deaths by age, sex, race/ethnicity, cause of death, county, and year. After their initial data analysis, the researchers estimated death rates by age, year, and geographic region. Finally, they separated the data into 4 categories: large central metropolitan areas, large metro suburbs, small/medium metros, and non-metros, or rural areas.

They created 14 specific categories of deaths, including deaths of despair, as well as screenable cancers and influenza/pneumonia, which served as indicators of access to health services. A major feature of the ACA was to eliminating cost-sharing for key screenings for those with coverage; this element has been credited with closing disparities in states where low-income people can gain coverage under Medicaid expansion.

The story of declining life expectancy is a tale of those who die young, and of a divide between urban and rural America, the authors found. Rising mortality has been especially stark among 25-to-44-year-olds, largely due to the opioid crisis. Moreover, while rural areas struggled generally, in the later years of the study young adults saw rising mortality everywhere, from rural areas to large metropolitan areas.

“The trends vary by region,” Elo, a professor of sociology and part of Penn's Population Studies Center (PSC), said in a statement. "Large central metropolitan areas have done extremely well, particularly compared to the non-metropolitan areas that have done poorly. To varying degrees, that pattern is evident across the country."

"The biggest contrast we saw was between large metropolitan areas and their suburbs and non-metropolitan areas, which have moved in different directions," said Preston, a Penn professor of sociology and member of the PSC. "Between 1990 and 2016, non-metropolitan areas had rising mortality, which is extremely unusual in the context of life expectancy that has gotten better nearly every year for nearly every group for more than a century."

The stark differences between rural and urban America are seen in the fortunes of white men: the data show that white men in large central metropolitan areas had the biggest gains in life expectancy; the Middle Atlantic and Pacific regions gained 7.13 and 6.11 years over the study period, respectively. By contrast, white men in nonmetro areas of Appalachia, and the East and West South Central States—Alabama, Mississippi, Tennessee, Kentucky, Arkansas, Louisiana, Texas, and Oklahoma—saw gains of 1.42 to 1.80 years.

Obesity may contribute to the mortality rise, the authors found. Other research has shown that recent gains in cancer survival are tempered by the news that cancers related to obesity, such as pancreatic, liver, and stomach cancer, are accounting for a larger share of cases and occurring among younger patients. The authors graphed changes in life expectancy over changes in the obesity rate in 40 areas, and found, “Changes in obesity prevalence have greater correlation with geographic changes in life expectancy than any other variable that we examine.”

But poverty is more complicated. Poverty rates fell from 2011 to 2015, and were lower for those in rural areas than those in urban areas in all regions. Access to healthcare seemed to have a more positive impact than access to cash assistance. They authors found that educational attainment was the best predictor of life expectancy, and that “Increases in life expectancy were smaller in areas where dependence on government transfers grew the most between 1990 and 2015.”